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The Heterogeneity of Disability Trajectories in Later Life: Dynamics of Activities of Daily Living Performance Among Nursing Home Residents
Abstract and Figures
Paper is forthcoming in Journal of Aging and Health
Objectives: This study investigated the variability in Activities of Daily Living (ADL) trajectories among 6,155 nursing home residents using unique and rich observational data.
Methods: The impairment in ADL performance was considered as a dynamic process in a multi-state framework. Using an innovative mixture model, such states were not defined a priori but inferred from the data.
Results: The process of change in functional health differed among residents. We identified four latent regimes: stability or slight deterioration, relevant change, variability, recovery. Impaired body functions and poor physical performance were main risk factors associated with degradation in functional health.
Discussion: The evolution of disability in later life is not completely gradual or homogeneous. Steep deterioration in functional health can be followed by periods of stability or even recovery. The current condition can be used to successfully predict the evolution of ADL allowing to set and target different care priorities and practices
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... So, the studies that focussed on older populations tend to be consistent in that they often report trajectories with high levels of functioning, mostly report trajectories with decline, but do not report trajectories reflecting recovery of functioning [16,21,22]. Studies focussing on younger populations (~ 55-75 years) sometimes report recovery or fluctuating trajectories [13,[23][24][25], whereas studies that focus on older populations (75+) tend to report no recovery [16,21,22]. ...
... It could be possible that due to our shorter measurement intervals the rate of change has had a bigger impact in defining the trajectories than differences in the intercept. On the other hand, the absence of sex differences is not entirely anomalous; for functional limitations Bolano et al. [24] and Holstein et al. [58] do not report any statistically significant sex differences, and Comijs et al. [8] do not always identify sex differences for trajectories in cognition. In addition, a study on the differences in cognitive decline between men and women did not find these differences [59]. ...
Background
Using longitudinal panel data, we aimed to identify three-year trajectories in cognitive and physical functioning among Dutch older adults, and the characteristics associated with these trajectories.
Methods
We used Group-based Trajectory Modelling with mortality jointly estimated to identify trajectories, using a scale composed of 6 Activities of Daily Living (ADL) as a measure of physical functioning, and the short mini mental status examination (sMMSE) or the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a measure of cognitive functioning. Data came from 574 Dutch adults aged 75+, collected in five nine-month measurement waves (2015–2018) for the Longitudinal Aging Study Amsterdam.
Results
For physical functioning five trajectories were identified: ‘high’, ‘moderate’, ‘steeply declining’, ‘gradually declining’, and ‘continuously low’; and for cognitive functioning: ‘high’, ‘moderate’, ‘declining’, and ‘low’. Living in an institution, and being lower educated increased the probability of the two continuously low functioning trajectories, whereas old age and multimorbidity increased the probability of low physical functioning, but multimorbidity decreased the probability of low cognitive functioning. Associations for steeply declining physical functioning were absent. Being older and having multimorbidity increased the probability of gradually declining physical functioning and declining cognitive functioning. A higher prevalence of lung- and heart disease, cancer, and rheumatic disease was found in the gradually declining physical functioning group; and a higher prevalence of diabetes, cerebrovascular accidents, and cancer was found in the declining cognitive functioning group. High and moderate physical functioning and high cognitive functioning were characterized by being younger, community-dwelling, and higher educated. Having multimorbidity negatively predicted high and moderate physical functioning, but was not associated with high and moderate cognitive functioning.
Conclusions
This study identified trajectories comparable to studies that used longer time intervals, showing the consistent presence of heterogeneity in both physical and cognitive trajectories. Co-modelling mortality resulted in bigger group sizes for the more adverse trajectories. The favourable trajectories, containing most of the participants, were mostly characterized by absence of disease. The prevalence of chronic diseases differed between the declining trajectories, suggesting that certain diseases tend to induce cognitive decline rather than physical decline, and vice versa.
... Currently, functional disability is defined as a long-term complex process or a trajectory that might unfold not only in old age but also across the life course. The study field of functional ability trajectories is ample and comprises analyses centered on patterns both in late adulthood and old age in different countries (Diaz-Venegas & Wong, 2016;Lin & Kelley-Moore, 2017), including trajectories at the end of life (Edjolo et al., 2016;Gill et al., 2010;Lin, 2020;Wolf et al., 2015), and studies questioning the gradualist assumption of cumulative decline in functional status instead suggesting the high prevalence of punctuated equilibrium and nonlinearity in health histories , including healthdeclining and health-recovery transitions (Bolano et al., 2019). ...
... Consequently, our findings support studies questioning the overestimation of the gradualist assumption about the cumulative decline in functional health among individuals and populations (Bolano et al., 2019;. Our results show that punctuated equilibrium and nonlinearity in functional ability trajectories are as prevalent as gradual, cumulative decline. ...
Objectives: Despite the enormous advances in the field, most evidence about functional ability trajectories in old age comes from studies conducted in developed and high-income countries. This research aims to build on these previous advances to examine functional ability trajectories in Chile.
Methods: Drawing on a robust, publicly available 15-years panel dataset (2004-2018), and using sequence analysis, we examine functional ability trajectories types among four age groups (people aged 46-50, 51-55, 56-60, and 61-64 at baseline). Then, we analyze trajectories’ dynamics looking at intra-individual health-declining and health-recovery transitions between functional ability statuses, within each trajectory type. Finally, we assess how multiple baseline individual characteristics predict the likelihood of following a functional ability trajectory type, using multinomial regression models.
Results: Across all age groups, an important fraction (between 26%-50%) reports stable healthy trajectories, and between 10%-20% follow equivocal-declining trajectories (i.e., exhibiting both health-declining and health-recovery intra-individual transitions), suggesting that age might not be the main source of heterogeneity in functional ability trajectories. Overall, women, lower educated people, nonworking individuals, and people with a higher burden of chronic conditions at baseline, are more prevalent among health-declining trajectory types; however, these results are not constant across the age groups analyzed.
Discussion: This nationally focused study reinforces the feasibility and usefulness of an in-depth analysis of functional ability trajectories in old age. The study findings can be crucial to define different prevention strategies according to the functional ability path that an individual might follow, especially in countries like Chile that currently navigates the challenges of population aging.
... [11][12][13][14] Still, the interindividual variability in health trajectories and intervention response is extensive. The variability in intervention response is multifactorial and influenced by person-related factors such as heterogeneity in health and functional status in older populations, 15,16 provider-related factors such as staff attitudes, knowledge and resources, 17 and organizationrelated factors such as NH leadership and resources. 18,19 Another determinant of response is adherence to an intervention. ...
Objectives: Interindividual response variability to nutrition and exercise interventions is extensive in older adults. A group of nursing home (NH) residents participated in a combined intervention. The objective of this post-hoc analysis was to identify factors associated with intervention response measured by change in physical function and body composition.
Design: Post-hoc analyses in the Older Person's Exercise and Nutrition study, a 2-arm randomized trial. The primary outcomes were 30-second Chair Stand Test and composite scores combining physical function and fat-free mass. A secondary outcome was intervention adherence. A 12-week intervention of sit-to-stand exercises and protein-rich nutritional supplements did not improve chair-stand capacity vs control on intention-to-treat basis.
Setting and participants: Residents ≥75 years of age from dementia and somatic units in eight NHs in Sweden.
Methods: Logistic regressions were performed to define factors associated with response (maintenance/improvement) or nonresponse (deterioration) in 30-second Chair Stand Test, and with intervention adherence. Linear regressions were performed to explore factors associated with response in composite scores.
Results: Mean age of participants (n = 52 intervention, n = 49 control) was 85.8 years. Sarcopenia was occurring in 74%. Sarcopenia at baseline (P = .005) and high adherence to nutritional supplements (P = .002) increased the odds of response. Higher independence in daily activities increased the odds of adherence to sit-to-stand exercises (P = .027) and the combined intervention (P = .020). Allocation to the intervention group and higher self-perceived health were associated with higher composite scores.
Conclusions and implications: NH residents with baseline sarcopenia, better self-perceived health, and high adherence to nutritional supplements benefitted most from a combined nutrition and exercise intervention regarding chair-stand capacity and composite scores of function and fat-free mass. Adherence was related to higher grade of independence. Understanding factors associated with response and adherence to an intervention will help target susceptible residents in most need of support and to optimize the outcome.
... [11][12][13][14] Still, the interindividual variability in health trajectories and intervention response is extensive. The variability in intervention response is multifactorial and influenced by person-related factors such as heterogeneity in health and functional status in older populations, 15,16 provider-related factors such as staff attitudes, knowledge and resources, 17 and organizationrelated factors such as NH leadership and resources. 18,19 Another determinant of response is adherence to an intervention. ...
Objectives:
Interindividual response variability to nutrition and exercise interventions is extensive in older adults. A group of nursing home (NH) residents participated in a combined intervention. The objective of this post-hoc analysis was to identify factors associated with intervention response measured by change in physical function and body composition.
Design:
Post-hoc analyses in the Older Person's Exercise and Nutrition study, a 2-arm randomized trial. The primary outcomes were 30-second Chair Stand Test and composite scores combining physical function and fat-free mass. A secondary outcome was intervention adherence. A 12-week intervention of sit-to-stand exercises and protein-rich nutritional supplements did not improve chair-stand capacity vs control on intention-to-treat basis.
Setting and participants:
Residents ≥75 years of age from dementia and somatic units in eight NHs in Sweden.
Methods:
Logistic regressions were performed to define factors associated with response (maintenance/improvement) or nonresponse (deterioration) in 30-second Chair Stand Test, and with intervention adherence. Linear regressions were performed to explore factors associated with response in composite scores.
Results:
Mean age of participants (n = 52 intervention, n = 49 control) was 85.8 years. Sarcopenia was occurring in 74%. Sarcopenia at baseline (P = .005) and high adherence to nutritional supplements (P = .002) increased the odds of response. Higher independence in daily activities increased the odds of adherence to sit-to-stand exercises (P = .027) and the combined intervention (P = .020). Allocation to the intervention group and higher self-perceived health were associated with higher composite scores.
Conclusions and implications:
NH residents with baseline sarcopenia, better self-perceived health, and high adherence to nutritional supplements benefitted most from a combined nutrition and exercise intervention regarding chair-stand capacity and composite scores of function and fat-free mass. Adherence was related to higher grade of independence. Understanding factors associated with response and adherence to an intervention will help target susceptible residents in most need of support and to optimize the outcome.
... It could be possible that due to our shorter measurement intervals the rate of change has had a bigger impact in de ning the trajectories. On the other hand, the absence of sex differences is not entirely anomalous; for functional limitations Bolano et al. (52) and Holstein et al. (53) do not report any statistically signi cant sex differences, and Comijs et al. (8) do not always identify sex differences for trajectories in cognition. Moreover, our analyses included mortality, various diseases, age and level of education, which are all factors that differ by sex, which may have decreased the effect of sex itself to non-signi cance. ...
Background
Using longitudinal panel data, the aim of this study was to first identify three-year trajectories in cognitive and physical functioning among Dutch older adults. And second, to identify which main characteristics were associated with these trajectories.
Methods
Group-based Trajectory Modelling with mortality jointly estimated was used to identify trajectories, using a scale composed of 6 Activities of Daily Living (ADL) as a measure of physical functioning, and a short version of the mini mental status examination (sMMSE) or the IQCODE as a measure of cognitive functioning. Data came from 574 Dutch adults aged 75+, collected in five nine-month measurement waves conducted between 2015 and 2018 for the Longitudinal Aging Study Amsterdam.
Results
Five trajectories in physical functioning were identified: ‘high’, ‘moderate’, ‘steeply declining’, ‘gradually declining’, and ‘continuously low’. People that were older, lower educated, living in an institution, or suffered from diabetes or cerebrovascular accidents were more likely to follow a low or declining physical trajectory. For cognitive functioning four trajectories were identified: a ‘high’, ‘moderate’, ‘declining’, and ‘low’ trajectory. Old age, low education, living in an institution, and heart- and lung diseases were associated with continuously low or declining cognitive functioning. Mortality risks were highest among those experiencing the continuously low functioning trajectories.
Conclusions
This study identified trajectories comparable to previous studies that used longer time intervals, showing the consistent presence of heterogeneity in both physical and cognitive trajectories. Co-modelling mortality resulted in bigger group sizes for the more adverse trajectories. The favourable trajectories, containing most of the participants, were mostly characterized by absence of disease, whereas trajectories showing decline did not share a common indicator. Specific chronic diseases were associated with different rates of decline, however there was no factor that was associated with all declining trajectories; future research could focus on finding such an indicator.
... HMMs are also used in behavioral and criminal studies [12,13], as well as in psychology to model the learning process (e.g., [14]), and in economics and finance where they are known as regime switching models (e.g., [15][16][17]). Recently it has been used in health and population studies [18,19]. ...
This paper presents and discusses the use of a Mixture Transition Distribution-like model (MTD) to account for covariates in Markovian models. The MTD was introduced in 1985 by Raftery as an approximation of higher order Markov chains. In the MTD, each lag is estimated separately using an additive model, which introduces a kind of symmetrical relationship between the past and the present. Here, using an MTD-based approach, we consider each covariate separately, and we combine the effects of the lags and of the covariates by means of a mixture model. This approach has three main advantages. First, no modification of the estimation procedure is needed. Second, it is parsimonious in terms of freely estimated parameters. Third, the weight parameters of the mixture can be used as an indication of the relevance of the covariate in explaining the time dependence between states. An illustrative example taken from life course studies using a 3-state hidden Markov model and a covariate with three levels shows how to interpret the results of such models.
... Recently, a study of the trajectories of nutrition, cognitive function and autonomy over time and their impact on 5-year mortality in a French cohort of nursing home residents showed that these trajectories were better predictors of mortality than a single measurement of these parameters [7]. Several studies also examined the activities of daily living (ADL) disability trajectories in nursing homes and have suggested that there was considerable heterogeneity in disability trajectories, that the deterioration in ADL was not irreversible but was a predictor of short-term mortality [8,9]. ...
... Recently, a study of the trajectories of nutrition, cognitive function and autonomy over time and their impact on 5-year mortality in a French cohort of nursing home residents showed that these trajectories were better predictors of mortality than a single measurement of these parameters [7]. Several studies also examined the activities of daily living (ADL) disability trajectories in nursing homes and have suggested that there was considerable heterogeneity in disability trajectories, that the deterioration in ADL was not irreversible but was a predictor of short-term mortality [8,9]. ...
Background:
Previous studies have shown that older people can experience a considerable change in their physical performance (PP) over time.
Objectives:
To identify PP trajectories and their association with mortality among nursing home residents who were followed up for 3 years.
Design:
Three-year longitudinal observational study.
Setting:
Subjects of the SENIOR cohort.
Subjects:
Six hundred and four nursing home residents with a mean age of 82.9 ± 9.1 years.
Methods:
Baseline characteristics and the date of death were collected from the medical records. PP was assessed annually by the short physical performance battery (SPPB) test. Multiple imputations were performed to manage the missing data. PP trajectory groups were estimated using latent growth curve analysis. Cox proportional hazard regression models were applied to examine the risk of mortality according to the PP trajectory groups.
Results:
Three PP trajectory groups were identified: slow decline (N = 96), moderate decline (N = 234) and fast decline (N = 274). After adjustments for potential confounding variables and the baseline SPPB scores, the residents in the fast decline and moderate decline trajectory groups had an increased risk of mortality compared to those in the slow decline trajectory group, with hazard ratio values of 1.78 (95% confidence interval [CI] = 1.34-2.26) and 1.37 (95% CI = 1.10-1.66), respectively.
Conclusions:
PP trajectories provide value-added information to baseline geriatric assessments and could be used for predicting 3-year mortality among nursing home residents. It may be important to regularly monitor the SPPB score and signal an alert when a fast decline in PP is detected in older people.
... Another main finding was the identification of three groups with distinct, but parallel trajectories, all showing significant decline over time. A recent study of trajectories of ADL in NH residents identified different groups, which also included periods of stability or recovery [42]. However, this study was not specific to residents with dementia. ...
Background
In nursing homes (NH) the prevalence of dementia ranges from 50 to 84% and most residents have extensive physical-performance impairments. However, from time of admission, development of physical performance in NH residents with dementia remains unexplored.
Aims
To explore the overall trend in physical performance, associated characteristics, and groups following distinct trajectories from time of admission, in NH residents with dementia.
Methods
We followed newly admitted NH residents diagnosed with dementia (N = 583) from 47 NHs across Norway for 3 years. Individual assessments were conducted biannually, and main outcome measure was the Short Physical Performance Battery (SPPB). Facility-level characteristics included unit size, staff-to-resident ratio, and quality of the physical environment (Special Care Unit Environmental Quality Scale, SCUEQS).
Results
From time of admission, NH residents with dementia showed a significant overall decline in physical performance. Further, we identified three distinct trajectory groups with significantly different baseline physical-performance status (“good,” “moderate,” and “poor”), differences between groups maintained and all declined across time. Younger age, good general medical health, less-severe dementia, and less musculoskeletal pain were associated with both an average higher overall trend and better baseline group-belonging. Additionally, less apathy and more psychosis were associated with a higher overall trend, and agitation was associated with poorer baseline group-belonging.
Conclusions
To prevent excessive decline in physical performance in this population, NH clinicians should focus efforts specifically on assessment of physical performance at admission and on identification and management of musculoskeletal pain and neuropsychiatric symptoms.
... Our findings, however, suggest that for individuals, functional limitations-and potentially other health outcomes-do not necessarily follow a gradual pattern and are instead characterized by general stability interrupted by sporadic change. Our findings are consistent with recent research that has highlighted the relatively high prevalence of recovery and health variability among nursing home residents, who may be expected to experience more serious health declines than the general population (Bolano et al. 2018). Consequently, the use of gradualist longitudinal models to link exposure to disadvantage with health disparities potentially raises both methodological and substantive complications. ...
Longitudinal methods aggregate individual health histories to produce inferences about aging populations, but to what extent do these summaries reflect the experiences of older adults? We describe the assumption of gradual change built into several influential statistical models and draw on widely used, nationally representative survey data to empirically compare the conclusions drawn from mixed-regression methods (growth curve models and latent class growth analysis) designed to capture trajectories with key descriptive statistics and methods (multistate life tables and sequence analysis) that depict discrete states and transitions. We show that individual-level data record stasis irregularly punctuated by relatively sudden change in health status or mortality. Although change is prevalent in the sample, for individuals it occurs rarely, at irregular times and intervals, and in a nonlinear and multidirectional fashion. We conclude by discussing the implications of this punctuated equilibrium pattern for understanding health changes in individuals and the dynamics of inequality in aging populations.
The aim of this study was to compare the presence and severity of dementia in two large cross-sectional samples of nursing home residents from 2004/2005 and 2010/2011.
Demographic information as well as data on the type of nursing home unit, length of stay before assessment, physical health, regularly used prescribed drugs and Clinical Dementia Rating scale scores were used in the analyses. Logistic and linear regression models for hierarchical data were estimated.
The odds of the occurrence and of a greater severity of dementia were higher in 2010/2011 than in 2004/2005. Independent of the time of study, married men had more severe dementia than single men, and single women had more severe dementia than single men.
The findings may reflect the increase in the need for more nursing home beds designed for people with dementia between 2004/2005 and 2010/2011. © 2015 S. Karger AG, Basel.
Changes in human lives are studied in psychology, sociology, and adjacent fields as outcomes of developmental processes, institutional regulations and policies, culturally and normatively structured life courses, or empirical accounts. However, such studies have used a wide range of complementary, but often divergent, concepts. This review has two aims. First, we report on the structure that has emerged from scientific life course research by focusing on abstracts from longitudinal and life course studies beginning with the year 2000. Second, we provide a sense of the disciplinary diversity of the field and assess the value of the concept of ‘vulnerability’ as a heuristic tool for studying human lives. Applying correspondence analysis to 10,632 scientific abstracts, we find a disciplinary divide between psychology and sociology, and observe indications of both similarities of—and differences between—studies, driven at least partly by the data and methods employed. We also find that vulnerability takes a central position in this scientific field, which leads us to suggest several reasons to see value in pursuing theory development for longitudinal and life course studies in this direction.
Longitudinal methods aggregate individual health histories to produce inferences about aging populations, but to what extent do these summaries reflect the experiences of older adults? We describe the assumption of gradual change built into several influential statistical models and draw on widely used, nationally representative survey data to empirically compare the conclusions drawn from mixed-regression methods (growth curve models and latent class growth analysis) designed to capture trajectories with key descriptive statistics and methods (multistate life tables and sequence analysis) that depict discrete states and transitions. We show that individual-level data record stasis irregularly punctuated by relatively sudden change in health status or mortality. Although change is prevalent in the sample, for individuals it occurs rarely, at irregular times and intervals, and in a nonlinear and multidirectional fashion. We conclude by discussing the implications of this punctuated equilibrium pattern for understanding health changes in individuals and the dynamics of inequality in aging populations.
Reveals How HMMs Can Be Used as General-Purpose Time Series Models Implements all methods in RHidden Markov Models for Time Series: An Introduction Using R applies hidden Markov models (HMMs) to a wide range of time series types, from continuous-valued, circular, and multivariate series to binary data, bounded and unbounded counts, and categorical observations. It also discusses how to employ the freely available computing environment R to carry out computations for parameter estimation, model selection and checking, decoding, and forecasting. Illustrates the methodology in actionAfter presenting the simple Poisson HMM, the book covers estimation, forecasting, decoding, prediction, model selection, and Bayesian inference. Through examples and applications, the authors describe how to extend and generalize the basic model so it can be applied in a rich variety of situations. They also provide R code for some of the examples, enabling the use of the codes in similar applications. Effectively interpret data using HMMs This book illustrates the wonderful flexibility of HMMs as general-purpose models for time series data. It provides a broad understanding of the models and their uses.
Objectives:
To describe the functional dependence progression over time in older people living in nursing homes (NHs).
Design:
A systematic review of the literature was performed. Studies involving individuals 65 years and older living in NHs, describing their functional decline, improvement or stability in activities of daily living (ADLs), were eligible. The search strategy was applied in MedLine, Cochrane, CINAHL, and SCOPUS databases; aimed at identifying an unbiased and complete list of studies, searching by hand was also performed. The methodological quality of the 27 studies included was assessed.
Results:
Functional trajectories were documented mainly through multicenter study design including sample size ranging from 2 to 9336 NHs, from 1983 to 2011 throughout a single or multiple follow-ups (>20). The average rate of decline was expressed in different metrics and periods of time: from 3 months with a decline of -0.13 points of 28, to 6 months (-1.78 points of 2829) to 1.85 years (-0.5 points of 6). Eating and toileting were the most documented ADLs and the decline is approximately 0.4 points and 0.2 to 0.4 points of 5 a year, respectively. Among the covariates, individual factors, such as cognitive status, were mainly considered, whereas only 13 studies considered facility-level factors.
Conclusions:
Findings report the slow functional decline mainly in women living in US NHs, in years when residents were admitted with a low or medium degree of functional dependence. Considering that in recent years residents have been admitted to NHs with higher-level functional dependence, studies measuring each single ADL, using standardized instruments capable of capturing the signs of decline, stability, or improvement are strongly recommended. Among the covariates, evaluation of both individual and facility-level factors, which may affect functional decline, is also suggested.
Life course research investigates how human lives and events unfold over time, at both the individual level and larger levels, such as within families or nations. At the individual level, life course research is concerned with the development of individuals as they age, as well as with between-person differences in development. Such differences often exist across sexes, races, socioeconomic classes, and other characteristics. Importantly, the birth cohort to which an individual belongs plays an important role in shaping development, as do period events (e.g., economic depression). Trajectory methods have emerged over the last several decades as important tools for investigating life course dynamics, including between-person differences in development.